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From Heartbeat to Straightline- A Butterfly’s First Journey

This post is written by Devorah Goldberg, RN, BS, a bedside nurse on a general medical-surgical unit at NYU Langone Medical Center. Ms. Goldberg is a graduate student in the Adult Nurse Practitioner program at Hunter-Bellevue College of Nursing and received her baccalaureate degree in nursing from Adelphi University in 2013. You can read more by Devorah Goldberg and her life as a registered professional nurse – the meaningful relationships with patients, families and colleagues and her experiences facing rough spots as she moves along her journey as novice nurse on her blog, Tales of RN DG.

The staggered breaths painted shapes on the monitors. It jotted out perfect waves for one minute, and childlike scribbles the next. Those scrawled shapes relayed fluctuating signals; between hope and dread, between life and death. It was as if the ‘angel of death’ was there, had his sword in hand, target area marked, blade in place, but hesitant to make the hit. The breaths were present, but were the waves of storm rather than the waves in a surfers dream; rocky, damaging and unpredictable. The heart beat like a stationary race-car, rapid but thready, and unable to perfuse the body’s arterial racetrack. The translucency of the skin, windowed a dense yet motionless being.

Lips moved in prayer, while minds weighed the depth and upshots of their decisions. DNR. Legs raced as if on a mission, but never leaving as far as the edges of the bed. The corridors signaled the finish line, only centimeters away but reaching it meant the end was met, so the feet tread those areas cautiously. Those lips whispering prayers, dreaded, yet awaited the finish line.

The hours passed by. The screens fluctuations between the dreaded straight line and a perfect QRS wave confused the humans reading the signals. They asked me if it was the end, the monitor seemed unsure. I enter the quarters of the beating monitors possibly masking a life gone by; I am face to face with the thin wrinkled being curled up in the sheets, gasping for each breath, and a morphine infusion running in attempt to wash the pain away.

I felt the pulse. Thready and fast. It seemed to weaken as the seconds passed by. I kept my hand on the pulse, for at that moment it was the only sign of life, yet proof of its nearing end. Perhaps if I let my fingers go, that life might slip away, right through my fingertips.

My job is to promote life, and here I was anticipating death. My job is to chase away the ‘angel of death’ and here I felt like mapping out the directions for his next stop.

The ‘angel of death’ was well acquainted with the being curled up in the wrinkled sheets; the ‘angel of death’ had chased this being before. He didn’t wait till her 93 years to greet her. His multiple introductions to this being began over 65 years prior when she cooked for the Germans in the barbed wired gates of Auschwitz. The ‘angel of death’, marked his target back when she was out there fighting diseases in the concentrations camps, he was there when she used to sneak in potato peels to share with her bunk mates, he was there every morning when she awoke before sunrise to the threatening barks of the soldiers on guard.

Now she can surrender, because she has already made her victory. Every day that she lived, and made lives through the offspring she produced and raised, made her the victor. We watched as her chest rose and fell with trepidation, each movement using much effort, until all efforts were used. We called the doctor, he marked the time, and we covered her. Her soul had won its last fight.

The monitors stop, their frantic scribbles and the straight line of defeat stretches to eternity; and our hands meant for healing are cuffed to our backs preventing us from evading the inevitable footsteps of ‘the end”. Yet perhaps an even greater challenge is when that line marches on, merging with all the other listless strings of lifeless pulses. This was the first, so it hurt; but so did my first IV insertion and the many ‘firsts’ of painful things I had to initiate for the good of the humans it was inflicted upon. Time and experience forms an armored defense that can make each patient’s death a little less personal and a little more algorithmic. Experts might argue that such is an uncomfortable inevitable, but deems it unwise to bear the burden of each meeting with the ‘angel of death’. Yet one can also choose to take each opportunity to familiarize oneself with the tragedy it brings and practice the touch of caring that goes beyond the life of the being in the bed sheets. The challenge is to continue to be the blessing that escorts one’s journey from one world to another.

How can we be that blessings despite the forces that monotones those moments into listless tunes with each death we encounter? Dr. Vidette Todaro-Franceschi , RN PhD FT advises that it is how one faces death that prevents that burnout, that oscillating rhythmicity, that predictable sensation we may acquire as we repeatedly guide patients and families towards their loved one’s line of defeat . How can we conquer that intoxicating compassion fatigue hovering and buzzing over our nursing care, threatening to sting our compassion with every straight lined monitor and pulseless being that we encounter?

We swap that hovering sting with a “butterfly power” and we “flutterbye”.

Dr.Vidette Todaro-Franceschi, RN, PhD, FT coined this verb based on meteorologist Edward Lawrenz’s idea of the “butterfly effect”. The flapping wings of a butterfly that we see are connected to another event somewhere out in this world, and we were meant to witness it for a reason.

Dr. Vidette Todaro-Franceschi describes nurses providing care as butterflies flapping their wings, We think we are a separate entity providing care for a specific human being, but we are really one entity with the human being cared for. We are present during this most vulnerable and unforgettable time in a patient and their loved ones lives, because we were meant to be there and be a part. To be truly compassionate is not to see compassion as what a caregiver does, but to view our nursing care with a sense of belonging.

Wiklund and Wagner write how we are one with individual and their family, we are mutually engaged and must acknowledge our own and the other’s dignity and vulnerability to consistently provide compassionate care. We must view each experience as event connected to us, that we are a part of it; we are one with the patient and the experience.

Death happens to each person only once. When we guide those through that death path, it is a first for us, as one entity, at that time. The first one always hurts; and so with each race to meet that straight line, we must slip out of our cocoon and flap our wings with our patient. Each race confronted is a first; to flap our wings, to “flutterbye”.

Every greeting with the ‘angel of death’ should not build a comfort and familiarity that dampens the sadness that rides along with its presence, rather each experience forms and molds us. That is what will define one’s commitment towards learning and perfecting our practice and skill of caring. Rather than be smoothed out and molded, with each experience I hope to be sculpted and refined.

From my ‘Novice’ meeting to my ‘Expert’, I shall attempt to not to lose sight of the person under the sheets, the being behind the numbers and the family tiptoeing close by.

Written by Devorah Goldberg, RN, BSN

November 3, 2014

author: Editorial Staff

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This post is written by Devorah Goldberg,

HealthCetera

The Last Thousand Words

This guest post is written by Rusty Greene, RN, a student in the doctor of nursing practice program at the Hunter–Bellevue School of Nursing in New York City. He was a student last spring in CHMP senior fellow Joy Jacobson’s narrative writing class for graduate nursing students. Names have been changed in this post to protect anonymity.

Two years ago, I got a tattoo. I never thought it would help someone die.

My right upper arm is covered with a sketch of a seahorse. My uncle and my grandfather have the same tattoo. Both of them were in the navy. They got the tattoo because the seahorse symbolized strength and determination.

I got mine for different reasons. When I was at an aquarium several years ago, I saw the seahorses. They are strange creatures indeed. The males give birth and they are coated in a crusty layer of bone. The wings on their backs flicker like tiny prehistoric appendages. After the fathers give birth, they care for a brood of over 1,000, knowing that more than 950 of them won’t survive.

Seahorses are rugged and resilient. But they also bend the rules of gender. They turn the concept of caring on its head. The concept of “nursing” is not particular to the female of the species.

This is something I understand because I’m a male nurse.

In nursing school, I took many courses on compassion, the empathic response, and palliative care. While I believe anyone is capable of mastering these skills, the tone of these subjects often takes a female perspective. This is particularly true when discussing burnout and fatigue. In fact, the concept of compassion fatigue has been bandied about over the past few years as a very real and uncomfortable condition for nurses and caregivers in general. It is often discussed in the context of having a healthy work/life balance, where a nurse must juggle the demands of caring for strangers only to go home and tend to children, a husband. and a mortgage.

Additionally, when discussing care of the dying, medical literature sometimes goes to the other extreme, providing a sometimes cold and cookie-cutter set of guidelines to help patients “pass.” An Internet search will give you several examples. To combat the sterile nature of these reports, some will say that it is okay to cry with your patients and hold their hand when they are dying. I had a professor in nursing school who said she even climbed into bed with a patient and held her as she died of breast cancer. To me, that seems like a bit too much.

So the messages are mixed. Have compassion but don’t deplete yourself. Follow best practices but tailor them to your own nursing style. Have a big heart but be a man. More often than not, these messages remain muddled. But sometimes, circumstances can create the perfect moment of clarity.

It was Saturday night and Alex was dying of AIDS.

I remember walking in to bathe him near the end of my shift. I entered his room with a basin full of warm water and some liquid soap. As is almost always the case with those who are dying, the room was preternaturally still, as if the air was waiting for the event common to us all but rare in its profundity. Alex was moving on, expiring, “going to the next life.” All of us only get to do it once and it is a singular experience. The atmosphere seems to know this.

I pulled back Alex’s sheets to reveal his frail and failing body. From feet to neck, he was covered in tattoos. They were intricate, colorful designs that swirled on his flesh, dancing this way and that. Then I looked into Alex’s eyes and I saw terror. His “moving on” wasn’t going to be easy. And I had to find a way to comfort him.

I showed him my tattoo and explained its significance. He smiled as best he could and said, “Nice.”

As I was washing his leg, I tentatively asked him about a palm tree and some goldfish drawn on his knee. He explained as best he could about getting that particular tattoo in Florida when he was on vacation with an ex-girlfriend. And at that moment, I saw something soften in his eyes. He went on to describe several more images on his body. A series of stars drawn in Amsterdam on his right shoulder. A black butterfly on his left pectoral muscle that he called “Dark Hope.” The more he shared, the more he relaxed. “Have a good night,” I said softly when I was finished.

“You too,” he said.

Alex died the next day.

Somewhere in between the lectures, the textbooks and the life experience, a space for healing was created. There were no tears. There were no hugs. It was just two guys talking about their tattoos. But it was deeply emotional. I didn’t feel exhausted or distraught or less of a man for caring very deeply about my patient. And Alex finally got some rest.

They say a picture is worth a thousand words. That night they were worth far more than that.

October 31, 2014

author: Editorial Staff

1 Comment

This guest post is written by Rusty

HealthCetera, Policy

What Would #ThisNurse Say? #NYT, We Are Not Just, “Some Nurses.”

This post is by CHMP’s graduate fellow, Amanda Anderson, RN. Amanda is a practicing bedside nurse in Manhattan, and a grad student at the Hunter-Bellevue School of Nursing, where she co-directs The Nurses Writing Project. Her personal site, This Nurse Wonders, hosts all of her writing, and she tweets @12hourRN.

I gotta say it: I really didn’t want to write about Ebola again. I really did search for an alternative topic, but it’s clear from the media frenzy of the past week’s events – an infected doctor gallivanting around New York City, followed by an Ebola-free nurse-turned political prisoner – that nursing voice on this topic is still direly needed, and still sadly missing.

While nurse-centric reporting has picked up in other media outlets, the Times has largely stuck to its age-old beat – nurses are nameless, unauthorized to speak, and not worth quoting. Perhaps the piece that makes this most evident this week, is Anemona Hartocollis and Nate Schweber’s account of the stigma that the employee’s of New York City’s Bellevue Hospital face while currently treating Ebola. Honestly, after “Bellevue Employees Face Ebola at Work, and Stigma of It Everywhere,” I’ve toyed with the idea of cancelling my subscription and switching to the Post, because it really doesn’t read much different.

I’m sad, and a little flabbergasted by this piece. It speaks of stigmas Bellevue workers are facing since Ebola came to town – an important topic, and a perfect opportunity for nurse input. While I am sure that the burden of high profile care for Dr. Spencer and a condition as dangerous and unfamiliar as Ebola, is stressful and emotionally taxing, this article does little to break down the stigma that it speaks of. In contrast to Emory Health’s full disclosure of care protocols, this is wasteful public relations fluff. Where expert nurse opinion may have offered salve to the burns of misinformation, this collection of random quotes from titled physicians and food cart workers instead fanned its flame.

While any number of nurses could have commented in a way that discredited the reported stigma, not one was named or quoted. Instead of an infection control nurse talking about the procedures employees follow when entering and exiting the hospital (do they shower after work at Bellevue, as they do at Emory?), or the Chief Nursing Officer speaking about the counseling and supportive practices given to nurses caring for patients, nurses were referred to en masse as, “some nurses,” or “workers.” Instead of a union steward discussing the bargaining that is likely taking place to ensure that Bellevue nurses are adequately trained and units safely staffed throughout the care of this patient, nurses filed rank with the unskilled, unnamed and unauthorized – silently embracing the stigma, perhaps.

Sources, as listed by NYT reporters Anemona Harticollis and Nate Schweber, in their article, “Bellevue Employees Face Ebola At Work, and Stigma of It Everywhere,” from October 29, 2014.

The message behind this article is clear, through the language of speech that surrounds each person interviewed – nurses are not important enough to be identified, to be trained to speak openly to the media, or to be titled. While the man who sells coffee on the street shares his name and opinion, the expert, educated nurses within the hospital are shushed. Perhaps the contrast between those allowed to speak and those quoted in anonymity exposes a larger truth: Unless we are at a staged press conference, or whistle blowing with a lawyer, nurses are to remain the quiet ghosts of healthcare.

What would this nurse say, as my pithy title so blaringly asks? I’d say, nurses, start asking why the authors of an article in The New York Times can get away with quoting and titling the man who pushes patients down the hall, but you, the educated, credentialed professional are not sought after. I’d say, prepare yourself to speak to these reporters; start by reading your employer’s media policy, and asking your public relations department for nurse-specific media training. Remind them of your worth as an expert whose voice of experience is vital in current conversation. Tell them that with one sentence, a well-spoken nurse might have changed the course of this article from tabloid fodder, to a positive and effective public information piece: Ebola care is challenging, but because we are trained in x, y, z, and because we want to see our patient, and our community remain healthy, we push through with vigilance and skill.

Without our names, our titles or our words, we will continue as, “…some nurses,” allowing those without our expertise to speak for us, and own our care.

October 30, 2014

author: Editorial Staff

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This post is by CHMP’s graduate fellow,